Application for Enrollment in Medicare Part B (Medical Insurance)

Application for Enrollment in Medicare Part B (Medical Insurance) (CMS-40B)

Documents and Forms

Document Name Document Type
Form CMS-40B (SP) Application for Enrollment in Medicare Part B (Medical Insurance) Form and Instruction
CMS-40B Telephonic Attestation.docx Instruction
CMS-40B (SP) Solicitud De Inscripcion En La Parte De Medicare (Seguro Spanish_CMS-40B_508_Enabled revised.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf Form and Instruction
CMS-40B Application for Enrollment in Medicare Part B (Medical I CMS-40B-2024 Redesign_.docx Form and Instruction
CMS-40B Enrollment Screenshots Enrollment Screenshots for CMS-40B.docx Form and Instruction
CMS-40B Current form redlined (1).pdf Track Change - CMS-40B IC Document

Information Collection (IC) Details

IC Title:	Application for Enrollment in Medicare Part B (Medical Insurance)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-40B (SP)	Solicitud De Inscripcion En La Parte De Medicare (Seguro Medico)	Spanish_CMS-40B_508_Enabled revised.pdf	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-40B	Application for Enrollment in Medicare Part B (Medical Insurance)	CMS-40B-2024 Redesign_.docx		Yes	No	Fillable Printable
Instruction			CMS-40B Telephonic Attestation.docx		Yes	Yes	Printable Only
Form and Instruction	CMS-40B	Enrollment Screenshots	Enrollment Screenshots for CMS-40B.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,184,546	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,184,546	115,831	1,068,715
Annual IC Time Burden (Hours)	292,820	27,532	265,288
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change - CMS-40B	CMS-40B Current form redlined (1).pdf	03/21/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.